PREHOSPITAL PEDIATRIC SUPPLEMENT INFANTS AND CHILDREN MODULE 1994 DOT EMT-Basic

1. 1 PREHOSPITAL PEDIATRIC SUPPLEMENTINFANTS AND CHILDREN MODULE1994 DOT EMT-Basic

2. 2 Define Emergency Medical Services for Children (EMSC). A program designed to reduce child and youth mortality and morbidity due to severe illness or trauma.

3. 3 Oklahoma Resource Center: EMSCRC Department of Pediatrics Section of General Pediatrics Room 1303 P.O. Box 26901 Children�s Hospital of Oklahoma Oklahoma City, OK 73190 (405) 271-3307 Fax (405) 271-8709

4. 4 Methods/Mechanisms of Injury Prevention for Infants and Children. Teacher training in First Aid & CPR. Require CPR certification for High School graduation / drivers license. Primary Care Providers who teach child injury prevention. Injury Prevention programs taught in schools. EMT�s Paramedics teach Injury Prevention in their community.

5. 5 Developmental Characteristics Neonate Infant Toddler Preschooler School age Adolescent

6. 6 Neonate First 4 weeks of life Totally dependent on others Birth defects/unintentional injuries common Do not present any special assessment challenge

7. 7 Infants (0-1 years) Emotionally tied to parents If possible, let parents hold the infant Complete scene size-up & initial assessment from across the room if possible Start with heart and lungs & end with head

8. 8 Toddlers (1-3 years) More challenging Do not like to be touched Fear separation from parents Do not want clothes removed Do not like oxygen mask over their head Fear pain May view injury as some form of punishment

9. 9 Assessing the Toddler Remain calm Speak smoothly Allow security object/distraction Decide essential physical assessment parts Get through them the best you can Use toe to head approach

10. 10 Preschoolers (3-6 years) Concrete thinking, literally interprets what they hear Vivid imaginations/dramatize events Issue of modesty Vocabulary Aware of death Afraid of blood, pain, & permanent injuries

11. 11 Assessing Preschoolers Explain what you are doing Allow child to see and touch equipment Allow child to sit in parents lap if possible Be honest, tactful, and direct Cover bleeding injuries as soon as possible Explain the obvious Security object/use for assessment

12. 12 School Age (6-12 years) More cooperative/curious Able to rationalize/concerns about death & disability Easiest to manage/ understand what EMS is Maturity levels Remember that illness or injury may cause them to regress Issues of modesty Fear disfigurement, permanent injuries

13. 13 Assessment School Age Treat them with respect Be honest Explain using appropriate language

14. 14 Adolescents (12-18 years) Use concrete thinking/abstract thinking skills Invincible/take more risks Fear disfigurement May get different responses when away from authority figures Preoccupied by their bodies/modesty issues Mass hysteria

15. 15 Assessment Adolescence Used relaxed approach Smile, speak softly, and slowly Gain their trust Be honest - up to a point Same sex for injuries to genitalia Be tolerant of �mass hysteria� reactions Don�t get caught up in it

16. 16 Anatomical Differences Proportionally larger tongues Diameter of trachea 1/3 the diameter of a dime 4 to 5 mm. /Adult 20 mm. Head proportionally larger Younger than 9 months typically cannot support own head Skin surface is large compared to body mass More susceptible to hypothermia

17. 17 Anterior fontanel Closes between 12 & 18 months Abdominal musculature less developed Faster metabolic rate Cells use up oxygen faster Smaller circulating blood volume Bleeding must be stopped as quickly as possible Anatomical Differences Cont..

18. 18 Skin and Body Surface Area: Infants and young children are prone to hypothermia because their body surface area is larger in proportion to their body mass. Their skin is thinner and contains less subcutaneous fat. The same exposure to burn injury will result in deeper burns than an adult would receive. Newborns are further compromised because their temperature regulatory mechanisms are not well developed. Resuscitation and drug therapies are not as effective in a hypothermic child.

19. 19 The head of an infant or young child accounts for approximately 20% of the total body surface. Proportions of body surface area by body parts change throughout childhood, assuming adult dimensions by about 10 years of age. Skin and Body Surface Area:

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21. 21 Taking the Child�s History: For the young child, it will usually be necessary to obtain the history from the parent or care provider. Elements of the pediatric history are the same as for adults with the addition of: If the patient is an infant, birth weight and mother�s problems during pregnancy. Child�s estimated weight.

22. 22 Enhancing Cooperation Permit the child a �transition phase;� a chance to trust you before doing the physical exam. Project a calm friendly manner; get on the child�s level. �Can you point with 1 finger where it hurts?� If the child is uncooperative even with these measures, do not waste time attempting to complete the assessment as you already know much about the condition of the child and that his or her ABC�s are intact.

23. 23 General Guidelines for the Exam Use a toe to head approach which is less threatening to the child without a life threatening injury. Examine the infant or young child without suspected C-spine injury in the parent�s arms or on his or her lap. Take advantage of any opportunities the child presents for example, when the child cries it possible to make many of your important assessments. Color and moistness of the mouth. Presence of tears for hydration status. Breath sounds as the child inspires.

24. 24 Vital Signs Pulse Respirations Blood pressure Temperature Vital signs in the pediatric patient are age dependent (see table). Poorly taken vital signs in the pediatric patient are of less value than no vital signs.

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26. 26 Pulse: Brachial artery, carotid artery, or radial depending in size and age of child. Rate increase can occur due to anxiety, pain, fear, fever, and hypothermia can change rate. It is important to monitor pulse for at least 30 seconds, a full minute if possible. Rate can decrease from normal secondary to hypothermic, cardiac pathology and certain medications.

27. 27 Respiration�s: Observe respiratory rate before beginning exam. Increases can occur due to anxiety, pain, fear, fever, and hypothermia can change rate. Observe for the following: tachypnea, bradypnea, or periods of apnea retractions nasal flaring use of accessory muscles of respiration expiratory grunting crackles, wheezing

28. 28 Blood Pressure: Formula used to approximate the lower limit of systolic blood pressure by age in children under 2 years of age: 70 + (2 x age in years) The diastolic pressure is 2/3 of the systolic, Typical systolic blood pressure in children over 2 years: 90 + (2 x age in years) Blood pressure cuff size can affect accuracy of readings. Appropriate sized BP cuff bladder covers one-half to two-thirds of the child�s upper arm.

29. 29 Temperature: Rectal temperature > 38� C (100.4� F) in infants < 2-3 months of age. Rectal temperature > 40� C (104� F) in infants 3-24 months of age with no localized signs of infection (i.e., cold, cough). Rectal temperature < 36� C (96.8� F). Toxic appearing (looks ill) febrile child of any age. Tympanic temperature - current research of the accuracy of tympanic thermometers is on-going. Follow your local medical controls direction on the indications use and interpretations of data.

30. 30 Pulse Oximetry: If oxygen saturation is less than 95%, continuous monitoring should be performed and supplemental oxygen administered. Remember other gases such as carbon monoxide bind with hemoglobin much more readily than oxygen. In the event of possible exposure to these agents, the pulse oximeter reading is of no value.

31. 31 Signs of Respiratory Insufficiency/Failure Inadequate elimination of carbon dioxide (hypoventilation). Inadequate oxygenation of blood (hypoxemia)

32. 32 Early Signs and Symptoms: Respiratory rate too slow or fast Tachypnea (rate age dependent). Bradypnea (rate age dependent). Tachycardia (rate age dependent). Behavioral changes: Combativeness. Restlessness. Anxiety. Nasal flaring, use of accessory muscles.

33. 33 Late signs: Apnea. Cyanosis. Altered level of consciousness (ALOC) Bradycardia: definition 0 - 1 year: HR < 80/min. greater than 1 year: HR < 60/min. Cardiopulmonary arrest.

34. 34 Predisposing Factors Complete or severe partial upper airway obstruction. May be caused by epiglottitis, foreign body obstruction, croup. Signs and symptoms: Stridor Absent breath sounds

35. 35 Predisposing Factors Complete and/or severe partial lower airway obstruction. May be caused by asthma, bronchiolitis, foreign body aspiration, toxic gas inhalation Signs and symptoms: Wheezes Rales Tachypnea

36. 36 Predisposing Factors Lung disease. Includes pneumonia, CHF, near drowning. Signs and symptoms: Rales (wet lungs)

37. 37 Other Possible Causes Trauma ALOC Dehydration Metabolic derangement

38. 38 Most Common Respiratory Disorders: Asthma Bronchiolitis Croup Epiglottitis Foreign body obstruction

39. 39 Asthma Chronic recurrent lower airway disease with episodic attacks of bronchial constriction. Edema Increased secretion of thick mucus from the bronchial glands Spasm of the bronchioles and bronchi Decreased size of bronchiole and mucus causing lower airway obstruction

40. 40 Assessment Signs and symptoms: Respiratory signs-tachypnea, SOB, intercostal retractions, possible positioning to use accessory muscles. Coughing episodes which may trigger vomiting Color - pale or mottled; lips may be a deep, dark red, which progresses to cyanosis as hypoxemia increases. Mental status - apprehensive and confused. Breath sounds - prolonged expiratory respiratory and generalized inspiratory and expiratory wheezing.

41. 41 Historical Data Same as for adult with addition of: �How concerned are parents about this attack in relation to others?�

42. 42 Management Assess and monitor ABC�s. Administer high-flow, high concentration O2 (humidified if possible). Maintain the airway; be alert for possibility of emesis. If child has an inhaler or bronchodilator, assist parent or child to administer it as directed by protocol. Be prepared for ventilatory failure. Transport immediately.

43. 43 Bronchiolitis An infection of the lower respiratory tract. Signs and symptoms: Acute respiratory distress with difficulty breathing. Tachypnea Retractions Cyanosis Fever and cough Inspiratory and expiratory wheezing

44. 44 Management Assess and monitor ABC�s. Clear nasal passage and maintain airway. Administer high flow, high concentration 02 by mask. Be prepared to assist with ventilation. Transport and contact medical control.

45. 45 Croup An upper respiratory viral infection - Swelling and inflammation of larynx, subglottic tissue, and occasionally the trachea and bronchi. Signs and symptoms: Signs of respiratory distress: nasal flaring, retractions, tachycardia, tachypnea, pallor/cyanosis. Hoarse cry or voice. Seal-like barking cough. Inspiratory stridor, expiratory stridor in severe cases. Low grade fever.

46. 46 Historical Data All pertinent history with addition of: Does the child have any difficulty swallowing fluids? Is the child drooling? Commonly occurs in children between 6 months and 3 years. More common in the spring and fall. Usually follows cold symptoms by 2-3 days.

47. 47 Management Administer high flow, high concentration 02 with face mask, if child won�t tolerate - use flow by. Do NOT agitate with excessive physical exam or handling. Do NOT attempt to visualize the mouth and throat or use any instrument in the airway. Be prepared for respiratory arrest and assist ventilation. Transport rapidly and contact medical control. Let child assume position of comfort

48. 48 Epiglottitis Bacterial infection localized in the epiglottis, usually caused by hemophilus influenza, type B (H-flu). Signs and symptoms: Child will look very sick and have a high fever. Sitting in tripod position May be holding mouth open with tongue slightly protruding. Child has sore throat and refuses to swallow, drooling.

49. 49 Historical Data Does the child have fever? How high? How sudden? Does the child have a sore throat? Will they swallow? Acute swelling occurs above the glottis that may cause complete obstruction of the airway. Commonly affects children between 3-6 years of age but can occur in older and younger children. Onset is sudden and progression of respiratory distress and airway obstruction is rapid. Child may awaken with high fever, difficulty breathing, sore throat, and difficulty swallowing. This is a true medical emergency

50. 50 Management Assess and monitor ABC�s. Do NOT manipulate the airway. Avoid insertion of any object into the mouth for inspection. Do NOT make the child lie down, the swollen epiglottis may fall back and obstruct the airway. Administer high-flow, high-concentration oxygen. Have parent approach child with face mask, if not tolerated give 02 by flow-by. Minimize handling to prevent agitation and crying. Transport immediately and contact medical control. If airway obstruction occurs during transport: Administer positive pressure ventilation. Be prepared for gastric distention. Perform CPR if needed.

51. 51 Common Causes of Trauma to the Child Injuries are the major cause of death in children 1-14 years of age. Injuries cause more deaths than total of all other causes of death in children. Leading cases of death associated with pediatric trauma: motor vehicles 43.8% burns 14.9% drowning 14.6% aspiration 3.4% firearms 3.0% falls 2.0%

52. 52 Frequency of Injury to Major Body Parts Head 48% Extremities 32% Abdomen 11% Chest 9%

53. 53 Assessment Pediatric Trauma Perform the same assessment that you would on any other patient Remember - children with traumatic injuries die of hypoxia and hypoperfusion, secondary to specific injuries Be sure to control bleeding because it only takes a small amount of blood loss to create a critical situation

54. 54 Early Signs of ICP Blood pressure elevated, decreasing heart rate (bradycardia) Cheyne-Stokes respirations. Responsive to pain. Possible demonstration of decorticate or decerebrate posturing. Bulging fontanel, irritability, listlessness in infants. Altered mental status and three signs of Cushing�s Reflex (widening pulse pressure, decreasing heart rate, and abnormal respiratory rate) in children.

55. 55 Late Signs Of ICP Increase in systolic blood pressure while heart rate and respiratory continue to decrease Fixed and dilated pupils. Flaccid and unresponsive to pain.

56. 56 Management Assess and monitor ABC�s. If facial injury is present, protect the airway, suction carefully, and remove broken teeth. If signs of basilar skull fracture are present, do not insert a nasogastric tube, nasopharyngeal airway, or suction catheter into the nose. Stabilize and immobilize the cervical spine. Maintain the airway of the unconscious child with jaw thrust and oral airway.

57. 57 Hyperventilate with high-flow, high-concentration oxygen using a BVM at a rate at least 5 breaths per minute faster than the child�s usual respiratory rate. Cover scalp lacerations and apply pressure to stop bleeding, using your entire hand over areas of suspected skull fracture. Apply saline-soaked gauze to open skull fractures. Adequate perfusion to the brain must be maintained even with increased ICP, so seek ALS support to manage any associated hypovolemic shock with fluid resuscitation. Transport immediately Management Cont...

58. 58 Spinal Cord Injury Major causes: Falls MVA Sports injuries Occurs in approximately 1% of all injured children; 18% of children injured in a motor vehicle crash. It is not as common in children as in adults.

59. 59 Anatomy and Physiology Physiologic differences in a child�s spinal cord are present until eight years of age. There is greater mobility in the cervical spine of a young child because vertebrae are wedge shaped. Because head is heavier, greater stress is placed on the spinal cord in flexion-extension injuries. Fulcrum of neck motion occurs much higher in children (at C2-3 level), leading to more common injuries at the C1, C1, and C3 levels. Neck muscles of an infant are not well developed enough to compensate for the force of some injuries.

60. 60 Child Abuse Child abuse is harm or threatened harm to a child�s health or welfare by a person responsible for the child�s health or welfare. Includes sexual abuse, sexual exploration or non-accidental physical or mental injury.

61. 61 Neglect Includes failing to provide adequate food, clothing, shelter, or medical care

62. 62 Description of the Problem Child abuse is a complex health and social problem. It is on the increase in today�s society. It occurs in all socioeconomic groups. It is estimated that 1-3% of children in the United States are abused or neglected. Approximately 2,000-5,000 children die each year in the U.S. from injuries resulting from child abuse. In infants under 6 months of age, child abuse is a major cause of death, second only to SIDS.

63. 63 Psychosocial Contributors The abusive situation is usually precipitated by a crisis, which might be the �straw that broke the camel�s back�. Parental frustrations or an inability to cope Children with high risk for abuse. Chronically ill Premature infant Physically deformed Hyperactive and difficult to manage

64. 64 Physical Abuse Physical abuse involves trauma to the soft tissue, skeleton, central nervous system, abdominal organs, or teeth. Trauma inflicted by beating, burns, shaking, throwing against a wall or on the ground, binding, gagging, twisting extremities, poisoning, or starvation

65. 65 Burns Small, round burns or scars, often from cigarettes. Glove or stocking burns from immersion of hands or feet in hot water; no splash marks. Demarcated burns in the shape of the object, i.e., iron.

66. 66 Beatings Slap marks in the shape of a hand. Welts showing the shape of the instrument used. Suspicious bruises in various stages of healing. Active children normally have bruises over bony prominence such as the knees, shins, forehead, and lower arms which are caused by falls and play. Suspicious sites for bruises are the upper arms, trunk, upper anterior legs, sides of face, ears, neck, genitalia, and buttocks

67. 67 Shaken Baby Syndrome Baby is shaken in frustration and then thrown down. Bruising and torn blood vessels are caused as the brain stretches and bounces on each side of the skull, resulting increased intracranial pressure (ICP).

68. 68 Signs May see no physical marks on baby. May have signs of ICP. Baby may appear to be a SIDS victim, but true cause of death will be determined at autopsy

69. 69 Miscellaneous Patterns Human bite marks. Marks indicating the child was bound and gagged. Fractures noted by poor limb alignment or unwillingness to use an extremity. May be numerous fractures on X-rays

70. 70 Sexual Abuse These sexual contacts may include sexual assault or physical force, not only intercourse: Fondling Sodomy Exhibitionism Child pornography and prostitution Signs of sexual abuse are subtle

71. 71 Overt Signs of Sexual Abuse Bruising of the genitalia. Lacerations indicating vaginal or anal penetration. Semen on clothing or body. Discharge from the vagina or penis, indicating possible STD

72. 72 Emotional Abuse Emotional abuse involves failure of the parents to provide the child with support necessary for the development of a sound personality. This may occur by intimidation, subtle or overt rejection, threats, or excessive criticism. This is the most difficult and often goes unidentified

73. 73 Neglect Neglect involves the willful or unintentional absence of care for a child�s basic life or health in jeopardy. Lack of adequate nutrition. Lack of medical care

74. 74 Signs of Neglect Child unbathed and wearing unusually dirty clothes, poor hygiene. Poorly nourished, small and underweight for age. Inappropriately dressed for the season or the weather

75. 75 A legal obligation exists to report suspected abuse. A report of suspected abuse is only a request for an investigation. If additional incidents of abuse occur after the initial report has been made, make another request for investigation. If transportation to the hospital is imminent, report suspicions to the hospital personnel. Notify the Department of Human Services county office or call the Child Abuse Hotline at 1-800-522-3511. This number is answered 24 hours a day. In OK County call (405) 841-0800. Reporting Suspected Abuse

76. 76 Vital History How and when did the injury occur? Who was with the child or found the child and anyone witness the event? Has the child been moved from the scene? Are there other noticeable injuries that the parent or caregiver can�t account for? Is the injury probably environmental or lack of developmental skills of the child? Do your findings not match the history given? Does information change with further questioning?

77. 77 Documentation Guidelines Report everything heard and seen in a factual manner. Use direct quotations, not a summary of what was said. Include any discrepancies noted in stories of persons present

78. 78 Documentation Guidelines Record the child�s condition and physical injuries as you would for any case. Describe injuries by appearance, shape color, size location, and stage of healing. Do not describe shape of injury by object presumed to have caused the injury. Draw pictures of shapes of injuries and their location on the body.

79. 79 Documentation Guidelines Describe the setting of the child�s injury and the setting where the EMT first saw the child. Record the parents� and child�s behavior and their interaction with each other

80. 80 Reaction of the EMS Providers It is common for EMT�s and paramedics to have strong emotional reactions to child abuse cases, such as anger, frustration, disbelief, and horror. These feelings can get in the way of care. Remember you are the child�s advocate. The best way to help the child is to remove them from the situation and take them to the hospital.

81. 81 Children Dependent on High-Technology Equipment Children are now cared for at home by their parents with highly sophisticated equipment for a variety of chronic or terminal illnesses. Premature babies with chronic lung disease. Advanced cystic fibrosis. Chronic diarrhea. Heart defects who get fatigued sucking a bottle.

82. 82 Home Equipment Equipment found in the home includes: Ventilators, suction equipment, O2. IV infusion pumps Feeding pumps.

83. 83 Reasons Why EMS is Activated Parents have been taught to manage their child�s care and to treat most common emergencies. Generally called to help in times of crisis. Severe respiratory distress or respiratory arrest. Life supporting equipment malfunction.

84. 84 Management Monitor ABC�s. Support the efforts of parents who may already be providing emergency care such as CPR. It is not always necessary to take over for them. In cases of equipment malfunction, attach child to your equipment. Vendors will repair the child�s equipment. Provide rapid transport and have the hospital notify the child�s physician